Amber G. Paterson, Ph.D.,
Research Fellow, Department of Psychiatry

Treating distress is one of the ways those affiliated with
the Psycho-Oncology Program, a cooperative venture between
the University of Michigan Comprehensive Cancer Center (UMCCC)
and the Department of Psychiatry, are trying to help patients
deal with cancer. Distress is a problem that impacts individuals
with cancer and those around them. For example, distress in
medical patients has been associated with delays in immune
response, healing and recovery times, reduced survival times,
and increased utilization of medical and social services,
in addition to impairments in personal, social, and occupational
functioning (1, 2, 3, 4). Unfortunately, although these facts
are generally known, incorporating this information appropriately
into clinical practice can be difficult and has led to several
questions including: How does one identify and treat a distressed
patient most effectively? How and when is distress best measured?
Which interventions yield the best results? In an attempt
to answer these questions and improve the quality of care
provided to distressed cancer patients, Peter Trask, Ph.D.,
and Amber Paterson, M.S., in collaboration with Michelle Riba,
M.D., and Tim Johnson, M.D., Director of the Multidisciplinary
Melanoma Clinic, as well as faculty and staff in the Melanoma
Clinic and the Bone Marrow Transplant Program, are conducting
studies focused on screening, evaluating and treating distress
in these patients.

Melanoma accounts for only 5% of skin cancer cases, but
over 75% of skin cancer-related deaths (5), and continues
to increase in men and women faster than any other solid tumor.
Early treatment is especially important given that survival
rate and treatments depend on depth of tumor and spread of
disease (6, 7). This population is susceptible to demonstrating
a wide range of emotional distress in response to both the
primary and adjuvant therapies, as well as potential or perceived
changes to quality of life, and may respond to interventions
aimed at reducing distress. Given that several studies have
reported that baseline levels of emotional distress and coping
are significant predictors of recurrence of disease and survival
(8, 9), longitudinal studies of distress that include a pre-treatment
baseline assessment appear to be important.

Bone marrow transplantation (BMT) is used to treat a
variety of cancers (e.g., Hodgkin's disease, leukemia, breast
cancer, multiple myeloma). Recipients of bone marrow transplantation
undergo an intensive procedure requiring isolation and a lengthy
convalescent period (6 weeks in hospital) that often results
in significant physical and psychosocial morbidity (10, 11),
including reports of suicide attempts (12), and the development
of Post-Traumatic Stress Disorder symptomatology (13). Recent
research has found clinically significant scores on measures
of anxiety and depression in 30 to 50% of patients in the
months and years following transplant (14, 15, 16), including
persistence of symptoms for up to 6 years (15). Global ratings
of distress have been found to be elevated in as many as 93%
of patients over an average of 3 years post-transplant. Such
dysfunction has been found to be significantly higher than
similar ratings by both healthy controls and other cancer
patients (17, 18) and has been associated with longer hospital
stays, poorer treatment outcomes and lower survival rates
(19, 20). Additional areas of specific concern associated
with impairment and distress include pain, fatigue and sexual
functioning (21).

Melanoma and BMT are two areas where patients may experience
a significant amount of distress and may benefit from psychological
intervention. In particular, the potentially rigorous and
comprehensive treatments undertaken by these patients puts
them at greater risk for experiencing significant distress.
Normally, distressed oncology patients are referred to members
of the psycho-oncology program only when problems are noted
by someone on the consulting/ treatment team. One exception
to this is a pre-BMT psychological evaluation, in which Brook
Brines, Ph.D., routinely completes a psychiatric history and
assesses prospective recipients' levels of distress at the
time of admission. She suggested that an "early red flag"
would often be helpful in minimizing the impact of patients'
distress and ensuring as smooth a process as possible for
all involved. Given this, as part of two studies being conducted
with the help of an award from the Faculty Group Practice,
distress is being assessed at the time of initial consultation
in both the Melanoma and BMT programs to determine if earlier
identification of patient distress is possible and/or useful.

The basic design of the melanoma and BMT studies is essentially
identical. Upon arrival to the clinic and prior to any intervention,
patients complete a series of questionnaires on emotional
distress, quality of life, coping strategies and anxiety designed
to provide baseline levels of distress at initial contact
with the UMCCC. Those who go on to receive treatment at the
University of Michigan are asked to participate in a second
phase, in which distress is again evaluated following the
medical intervention and participants are divided by distress
level into low, medium and high distress groups. Within each
group, individuals are randomly assigned to either standard
medical care or standard medical care plus a psychological
intervention. Following the intervention, individuals are
again assessed and receive subsequent assessment at 6- and
12-month follow-up appointments to determine if distress has
returned. In this way, it is hoped that early predictors of
distress and efficacious methods for its reduction may be
identified so that they may be easily incorporated into clinical
practice.

Currently, the studies are in two separate phases. Although
the BMT study is still in the design phase, the melanoma study
has been running for the past month. During that time, 50
patients have agreed to participate in the first part of the
study, that which assesses distress at the time of consultation.
Of the 50 individuals, complete data has been obtained on
27 of them, with the majority of the remainder not having
had the opportunity to return the questionnaire package. Of
these 27 individuals, 43% are male and 57% are female. The
majority of participants are either currently working or are
retired and the overwhelming majority are Caucasian. Eighty-five
percent of the participants are married, with 7.4% being divorced,
and 3.7% being either never married or widowed. In terms of
education, 42.3% have completed at least high school and 34.6%
have completed college. The majority of participants reported
minimal use of alcohol, marijuana or other substances, and
53.8% reported never having smoked.

Of greater interest is the amount of distress individuals
are reporting at the time of presentation to the Melanoma
Clinic. Figure
1 presents the mean and range of scores on the Brief Symptom
Inventory, which is being used to determine the amount of
distress. The measure is scored with a mean of 50 and a standard
deviation of 10, such that scores above 60 are indicative
of moderate distress and scores above 70 representative of
severe distress. Looking at the BSI as a measure of overall
distress, it appears that individuals are presenting to the
Melanoma Clinic on average without a clinically significant
level of distress. Of greater importance is the wide range
of distress in individuals at this time point. Although the
group, on average, does not exhibit a significant level of
distress, there are several individuals who are exhibiting
significant emotional difficulties. Given that this is their
first exposure to the clinic, the current study is especially
interested in determining whether this level of distress remits
following psychological intervention.

Individuals reported using a variety of coping strategies
to deal with their illness, with "seeking social support"
and "use of problem-solving coping" being the two
most frequently used. Figure
2 presents the average scores on the various coping scales.
In terms of health functioning, the majority of individuals
reported having excellent or very good health in areas such
as physical functioning and mental health. Finally, initial
correlations between the variables revealed that higher levels
of distress were associated with more acceptance coping, more
trait anxiety, and lower levels of social functioning, vitality
and mental health.

What these preliminary data indicate is that while patients
are reporting average levels of distress at presentation to
the clinic, there is a wide variability, with some individuals
being significantly distressed. Those individuals who are
generally reporting healthy strategies of coping with the
stress of a possible diagnosis of melanoma are functioning
well. However, the data also suggest that individuals experiencing
higher levels of distress tend to utilize less adaptive coping
strategies, such as being confrontational or simply accepting
events. These individuals with increased distress and less
adaptive coping styles also report more difficulties in social
functioning at the time of their initial consultation to the
Melanoma clinic.

At this time we have not started the second part of the
study, the intervention. It will be interesting to determine
whether individuals distressed at consultation remain distressed,
and whether provision of a psychological intervention serves
to reduce that distress. Given the initial success of the
melanoma study, we are looking forward to implementing it
with the bone marrow transplant population.